W4L Intake - 2025
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Health History
Current Health History
Is this injury as a result of a Motor Vehicle Accident, or Work-related Injury?
Yes -Motor Vehicle Accident
Yes - Work-related Injury
No
If yes, what is the date of the Motor Vehicle Accident?
What is your main complaint? How did it start? How long you've experienced it?
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What your pain level of the complaint above?
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No Pain
Severe Pain
Please list any other complaints.
Please list any heath care professionals you have seen in the past?
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Have you ever had Chiropractic Treatment before?
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No
If yes how long has it been since your last treatment?
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Any recent spinal x rays? (When)
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Females Only, if you are pregnant, how many weeks are you pregnant?
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Medications
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Injuries
Injury
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Surgeries
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Personal Medical History - Select any that you've had or have:
Head & Neck
Headaches
Neck Pain
Sinusitis
Hearing Problems
Ringing in the Ears
Vertigo/Dizziness
Eye Problems
Vision Problems
Nose Problems
TMJ (jaw pain)
Sore Throat
Voice Changes
Chest, Lung, Heart & Skin
Chest Pain
Palpitations
Blood Pressure Issues
Asthma
Allergies
Insomnia
Night Sweats
Lung Problems
Shortness of Breath
Skin problems
Bruise Easily
Internal, Digestive & Miscellaneous
Nausea
Heartburn
Poor Appetite
Loss of taste
Bloating
Numbness
Fainting
Anxiety
Depression
Belching/Gas
Diarrhea
Constipation
Abdominal Pain
Liver Problems □
Kidney Problems
Frequent Urination
Urinary Tract Infections
Painful Urination
Prostate Trouble
Erectile Dysfunction
Incontinence
Hemmorhoids
Muscle Cramps
Diabetes
Nosebleeds
Stiff Joints and muscles
Low Energy
Poor Appetite
Scoliosis
Poor Posture
Gynecological (Females Only)
Congested Breasts
Lumps in Breasts
Cramps or Backache
Irregular Cycle
Excessive Menstrual Flow
Endometriosis
Hot Flashes
Menopausal Symptoms
Irregular Periods
Painful Periods
Absent Periods
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